NPIMap

Organization Active NPI

Kristin M Jackson LLC

Doing business as Advanced Urogynecology

  • Gynecology Physician
  • Maitland, FL
National Provider Identifier
1649748666
Registry record updated Dec 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gynecology PhysicianTaxonomy code 207VG0400X
Legal business name
KRISTIN M JACKSON LLC
Doing business as
Advanced Urogynecology
Practice address
260 Lookout PL Ste 201
Maitland, FL 32751-4485
Phone
(407) 898-9804
Fax
(407) 898-9805
NPI assigned
Nov 7, 2018
Last updated
Dec 26, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 26, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kristin Jackson, MDNPI 1861417859
Title
Owner
Phone
(407) 902-7400

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Gynecology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207VG0400X Primary

Addresses

Primary practice location

260 Lookout PL Ste 201
Maitland, FL 32751-4485

Mailing address

260 Lookout PL Ste 201
Maitland, FL 32751-4485
Phone (407) 898-9804

Other names 1

  • Advanced Urogynecology Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190116002408 FL Part B Supplier - Clinic/Group Practice 7113263831 Receives reassigned benefits from 8 practitioners
Practice locations: Lake Mary, FL; Maitland, FL

National Provider Directory

National Provider Directory

Locations

260 Lookout Pl
Ste 201
Maitland, FL 32751
Phone (407) 544-4014

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1541548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1545782400000",
    "number": "1649748666",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "260 LOOKOUT PL STE 201",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327514485",
            "telephone_number": "407-898-9804",
            "fax_number": "407-898-9805"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "260 LOOKOUT PL STE 201",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327514485",
            "telephone_number": "407-898-9804",
            "fax_number": "407-898-9805"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KRISTIN M JACKSON LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-11-07",
        "last_updated": "2018-12-26",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "KRISTIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "407-902-7400",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207VG0400X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology, Gynecology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Urogynecology",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Advanced Urogynecology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Maitland, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.